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EDITORIALS: G R Davies and S B Squire Doubts about DOTS BMJ 2008; 336: 457-458 [Full text]

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DOTS is trudging along well inspite of various odds

Allen P Ugargol   (8 February 2008)

DOTS can never be succesful !!

dr mohan devegowda   (10 February 2008)

National "Twin study" of DOTS efficacy

Ulf R. Dahle   (28 February 2008)

Re: DOTS can never be succesful !!

jyotirmoy ghosh   (8 April 2008)

DOTS is trudging along well inspite of various odds 8 February 2008
Allen P Ugargol, Research Fellow St. John's Institute of Population Health and Clinical Research, Bangalore - 560034 Send response to journal: Re: DOTS is trudging along well inspite of various odds	DOTS began with the clear mandate to ensure better treatment completion rates while simulataneously scaling up the number of cases under treatment and compliance rates. In looking at the odds that DOTS has had to face in a developing country such as India - with difficulty in accessing TB patients, stigma, gendered equations and discrimation playing significant roles, difficulty in roping in private practitioners into the DOTS programme, and great gaps in ensuring compliance, either due to migration of patients or lack of committment of patient/medical staff - it has achieved far more in terms of outreach, awareness and availability of treatment across the length and breadth of the country. While it is understandable why most public health programmes do not achieve goals set at the outset within the stipulated time, it is also good to take positives from the fact that DOTS has superceded and established itself as the mainstay of tuberculosis treatment and continues to draw on its vast reach and strength of commitment in achieving the goals. The time when things brighten up should not be too far away. Competing interests: None declared
DOTS can never be succesful !! 10 February 2008
dr mohan devegowda, GP mohan 's clinic 613 2nd main first stage indirnagar bangalore 560038 india Send response to journal: Re: DOTS can never be succesful !!	dear sir, As a GP working in urban set up with good practice where in Tuberculosis are seen at least 2-3 cases a month I can confidently tell the difficulties faced by patients. DOTS regime is controlled in our city by the Governament agencies. But health service is mainly by private agencies particularly by GPs and private hospitals. When I detect a patient with Tuberculosis and if sent to the place where DOTs regime is available the harrasment he or she gets is unimaginable. Inspite of the proof that patient is having tuberculosis he or she is not given the treatment unless the GOVT agency diagnoses themselves!! For this patient is made to run up and down several times. And the patient will not get the drug at the first instance he or she has to bribe [most of the times] and visit several times losing valuable earnings. Seeing all this most of the time patients themselves opt for the regular regime. And in general practice we have such wonderful relationship with the patients hardly very less number miss out the treatment.With out involving the GPs and not crediting them this DOTS regime can never be successful Competing interests: None declared
National "Twin study" of DOTS efficacy 28 February 2008
Ulf R. Dahle, Senior scientist Norwegian Institute of Public Health Send response to journal: Re: National "Twin study" of DOTS efficacy	EDITOR- In their editorial (1), Davis and Squire state it’s too soon to conclude on the efficacy of directly observed treatment short courses (DOTS) for tuberculosis (TB) treatment. They support Cox and colleagues (2) in that the evaluation of DOTS is hampered by other factors that may influence treatment outcomes. Norway and Sweden are sociodemographic, political and culturally comparable countries. However, the Norwegian TB control program fully complies with the DOTS strategy promoted by the World Health Organization and the International Union Against Tuberculosis and Lung Diseases, while that in Sweden does not. Most strategies for prevention of the disease in the two countries are otherwise comparable to that of the USA and most European countries (3). The two Scandinavian countries thus serve as an excellent "case-control model" to study the effect of DOTS on a national level, minimizing the interference of other factors that may affect treatment outcome. It was recently demonstrated, in a 12-year national study, that transmission of TB was stable in Norway, despite excessive import by immigration and increasing incidence (4). The study demonstrated that a high-income country with sufficient resources should be able to address imported TB and limit further spread, instead of casting the blame for domestic problems with TB control elsewhere. Immigrants from high-TB regions did bring with them more strains of Mycobacterium tuberculosis, but they did not significantly contribute to the spread of disease within the resident populations. Shortcomings of the national TB programme in Sweden however, have been revealed in parallel with the Norwegian success story (5). The Swedish Institute for Infectious Disease Control has been criticised by the National Board of Health and Welfare for not being able to stop the spread of drug resistant M. tuberculosis in Stockholm (6). It has been emphasized that introduction of DOTS to all patients is crucial to reduce the excessive TB transmission in Sweden (5). The two “twin countries” in northern Europe experience completely different epidemiological situations for TB. By introduction of obligatory DOTS to all patients, Norwegian health personnel appear to have reached an increasingly diverse population where they are able to accomplish prompt diagnosis and treatment (3, 4, 7). In Sweden however, the lack of DOTS introduction complicates the control of the same disease (5). These different TB-situations should provide strong arguments for introducing DOTS in all countries where this strategy has not yet been implemented. References. 1. Davies GR, Squire SB. Doubts about DOTS. BMJ 2008;336:457-458. 2.Cox HS, Morrow M, Deutschmann PW. Long term efficacy of DOTS regimens for tuberculosis: systematic review. BMJ 2008;336:484-487 3. Mitchell S. Don't Blame Immigrants for Tuberculosis. ScienceNow 2007; Nov 1st. Available from: http://sciencenow.sciencemag.org/cgi/content/full/2007/1101/1 4. Dahle UR, Eldholm V, Winje BA, Mannsåker T, Heldal E. Impact of immigration on the molecular epidemiology of Mycobacterium tuberculosis in a low-incidence country. Am J Respir Crit Care Med. 2007;176:930-935. 5. Kan B, Berggren I, Ghebremichael S, Bennet R, Bruchfeld J, Chryssanthou E, Källenius G, Petersson R, Petrini B, Romanus V, Sylvan S, Kalin M. Extensive transmission of an isoniazid-resistant strain of Mycobacterium tuberculosis in Sweden. Int J Tuberc Lung Dis. 2008;12:199- 204. 6. Dahle UR. Public health programmes: you don't know what you've got till it's gone BMJ 2004; 328: 1568. 7. Schwartzman K. "Them" and "Us": The Two Worlds of Tuberculosis? Am. J. Respir. Crit. Care Med. 2007; 176: 840-842. Competing interests: None declared
Re: DOTS can never be succesful !! 8 April 2008
jyotirmoy ghosh, Private practice Durgapur (w.bengal), India: 713212 Send response to journal: Re: Re: DOTS can never be succesful !!	The rigid way the DOTS regime is being applied by the Govt health care agencies in the primary and secondary levels will in many cases fail to achieve its objective. Radiologically positive cases refered from private practice are denied DOTS regime because the Govt primary care found these cases sputum negative. Thus index cases remain sources of fresh cases. Again DOTS regime have been stopped after six months as sputum are found negative although radiologically active disease remained. Thus the objective of DOTs i.e. preventing fresh cases and emergence of drug resistant TB are going by default in the application of this regime in Indian conditions. Competing interests: None declared